Form DS-1622 "Medical History and Examination for Children Age 11 and Younger"

What Is Form DS-1622?

This is a legal form that was released by the U.S. Department of State on June 1, 2020 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2020;
  • The latest available edition released by the U.S. Department of State;
  • Easy to use and ready to print;
  • Yours to fill out and keep for your records;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DS-1622 by clicking the link below or browse more documents and templates provided by the U.S. Department of State.

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U.S. Department of State
*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: 10-31-2023
Bureau of Medical Services, M/MED, Room L101, SA-1, Washington, DC 20522-0102
ESTIMATED BURDEN: 1 HOUR
MEDICAL HISTORY AND EXAMINATION
FOR CHILDREN AGE 11 AND YOUNGER
PRIVACY ACT NOTICE
AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (Title 22 U.S.C.4084).
PURPOSE: The information solicited from this form will assist in making a medical clearance decision for individuals eligible to participate in
the Department of State Medical Program while assigned abroad. (16 FAM 100 - 200)
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether
Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order.
More information on routine uses can be found in the System of Records Notice State-24, Medical Records.
DISCLOSURE: Providing this information is voluntary; however, not providing requested information may result in the failure of the individual to obtain
the requisite medical clearance pursuant to 16 FAM 211.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average one (1) hour per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection.
You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy
of this burden estimate and /or recommendation for reducing it, please send them to: M/MED/EX, Room L101 SA-1, U.S. Department of State,
Washington, DC 20522
DATE OF EXAM (mm-dd-yyyy)
I. DEMOGRAPHIC INFORMATION
TO BE FILLED OUT BY EMPLOYEE/SPONSOR OR PARENT
1. Name of Examinee (Last, First, MI)
2. Date of Birth (mm-dd-yyyy)
3. Sex
Female
Male
4. Full Name of Employee/Applicant/Sponsor
5. MED Number if known (Child examinee)
6. Place of Birth
State
Country
City
7. Agency of Employee/Applicant/Sponsor
STATE
USAID
FCS
FAS
U.S. Agency for Global Media
DoD Civilian
DoD Contractor
Non-Foreign Service Agency
Contracting Company
9. Purpose of Exam
8. E-mail Address of Parent/Sponsor
(Where You can be Reached for the Next 90 days)
New Dependent (pre-employment, newborn, adoption)
Primary:
In-Service Exam
Alternate:
Separation
10. Telephone Number of Parent/Sponsor
11. Post of Assignment and Estimated Dates of Arrival / Departure
(Where You can be Reached for the Next 90 days)
a. Proposed Post
EDA
(mm-dd-yyyy)
Primary:
b. Present Post
EDD
Alternate:
(mm-dd-yyyy)
To the individual and/or health care provider completing the medical history review /exam: The Genetic Information Nondiscrimination Act of 2008 (GINA)
prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the
individual, except as specifically allowed by this law. To comply with this law we are asking that you NOT provide any genetic information when responding to
this request for medical information. 'Genetic Information' as defined by GINA, includes an individual's family medical history, the results of an individual's or
family members' genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive
services.
Page 1 of 4
DS-1622
06-2020
U.S. Department of State
*OMB APPROVAL NO. 1405-0068
EXPIRATION DATE: 10-31-2023
Bureau of Medical Services, M/MED, Room L101, SA-1, Washington, DC 20522-0102
ESTIMATED BURDEN: 1 HOUR
MEDICAL HISTORY AND EXAMINATION
FOR CHILDREN AGE 11 AND YOUNGER
PRIVACY ACT NOTICE
AUTHORITIES: The information is sought pursuant to the Foreign Service Act of 1980, as amended (Title 22 U.S.C.4084).
PURPOSE: The information solicited from this form will assist in making a medical clearance decision for individuals eligible to participate in
the Department of State Medical Program while assigned abroad. (16 FAM 100 - 200)
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether
Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order.
More information on routine uses can be found in the System of Records Notice State-24, Medical Records.
DISCLOSURE: Providing this information is voluntary; however, not providing requested information may result in the failure of the individual to obtain
the requisite medical clearance pursuant to 16 FAM 211.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this collection of information is estimated to average one (1) hour per response, including time required for searching
existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection.
You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy
of this burden estimate and /or recommendation for reducing it, please send them to: M/MED/EX, Room L101 SA-1, U.S. Department of State,
Washington, DC 20522
DATE OF EXAM (mm-dd-yyyy)
I. DEMOGRAPHIC INFORMATION
TO BE FILLED OUT BY EMPLOYEE/SPONSOR OR PARENT
1. Name of Examinee (Last, First, MI)
2. Date of Birth (mm-dd-yyyy)
3. Sex
Female
Male
4. Full Name of Employee/Applicant/Sponsor
5. MED Number if known (Child examinee)
6. Place of Birth
State
Country
City
7. Agency of Employee/Applicant/Sponsor
STATE
USAID
FCS
FAS
U.S. Agency for Global Media
DoD Civilian
DoD Contractor
Non-Foreign Service Agency
Contracting Company
9. Purpose of Exam
8. E-mail Address of Parent/Sponsor
(Where You can be Reached for the Next 90 days)
New Dependent (pre-employment, newborn, adoption)
Primary:
In-Service Exam
Alternate:
Separation
10. Telephone Number of Parent/Sponsor
11. Post of Assignment and Estimated Dates of Arrival / Departure
(Where You can be Reached for the Next 90 days)
a. Proposed Post
EDA
(mm-dd-yyyy)
Primary:
b. Present Post
EDD
Alternate:
(mm-dd-yyyy)
To the individual and/or health care provider completing the medical history review /exam: The Genetic Information Nondiscrimination Act of 2008 (GINA)
prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the
individual, except as specifically allowed by this law. To comply with this law we are asking that you NOT provide any genetic information when responding to
this request for medical information. 'Genetic Information' as defined by GINA, includes an individual's family medical history, the results of an individual's or
family members' genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive
services.
Page 1 of 4
DS-1622
06-2020
Name of Examinee
DOB
II. MEDICAL HISTORY
ANSWER THE FOLLOWING QUESTIONS: ALL YES ANSWERS MUST HAVE A WRITTEN EXPLANATION WITH DATE OF OCCURENCE IN BOX IIA.
Does your child currently, or have a hisory of:
Yes
No
20. Joint, tendon or any orthopedic disorder?
Yes
No
21. Rheumatologic or immune disorder?
1. Frequent/severe headaches?
22. Malaria, tropical or other infectious disease?
2. Fainting, dizzy episodes, or syncope?
23. Any recent unexpected weight loss/gain?
3. Seizures or neurologic disorders?
24. Any skin or nail disorder
4. Eye or vision problems?
25. History of positive TB skin test, IGRA, or Tuberculosis?
5. Ear, nose, or throat problems, including hearing loss?
6. Allergies or history of anaphylactic reaction?
Yes
No
7. Cough, wheeze, shortness of breath, asthma?
25. Has your child been referred for any current or potential
special educational services, accommodations, or
8. Murmurs, palpitations, or other heart problems?
modifications (i.e.: IFSP, Early Intervention, IEP, 504
9. Rheumatic fever?
Plan)?
10. Diabetes, thyroid, or other endocrine disorders?
26. In the past seven years, has your child been in
psychotherapy/counseling or been prescribed medication
11. Hormonal or metabolic disorder?
12. Stomach, esophageal, or other intestinal problems?
to help with depression, anxiety, mood or stress?
13. Jaundice, hepatitis, gallbladder or other liver disease?
27. Has your child felt unusually depressed, sad, blue, or
had frequent crying spells which lasted more than 2 weeks
14. Intestinal, rectal problems or hernia?
at a time, within the past seven years?
15. Anemia?
28. In the past seven years, has your child had frequent or
16. Blood transfusions?
recurrent episodes of: difficulty relaxing or calming down,
panicky feelings, irritability, anger, feeling hyper, or
17. Urinary or kidney problems, blood in urine?
nervousness?
18. Cancer of any type?
29. In the past seven years, has your child experienced any
19. Premature birth, pre or post-natal complications?
emotional or physical symptoms related to a past trauma?
30. Is there anything else you would like to add about your child's health or well being that was not addressed in questions 1-29?
Yes
No
II a. Explanation required for "yes" answers to questions 1-30. Attach additional sheets as needed
III. LIST OF CURRENT MEDICATIONS (Include prescription, over the counter, vitamins, and herbs)
Drug Or Other Allergies
IV. HOSPITALIZATIONS/OPERATIONS/MEDICAL EVACUATIONS (Include all medical and psychiatric illnesses)
Illness or Operation
Name of Hospital
City and State
Date (mm-dd-yyyy)
Any knowing and willful omission, falsification, or fraudulent statement regarding material medical information may constitute a criminal
offense under 18 U.S.C. § 1001, and individuals committing such an offense may be subject to criminal prosecution. Employees of the
United States Government also may be subject to disciplinary action, up to and including separation, for any knowing and willing omission
or falsification or fraudulent statement of material information.
V. SIGNATURE OF PARENT OR SPONSOR (I certify I have read and understand the above statement.)
Date (mm-dd-yyyy)
Page 2 of 4
DS-1622
Name of Examinee
DOB
VI. INSTRUCTIONS FOR COMPLETION AND SUBMISSION OF DS-1622
MEDICAL EXAMINER
• Medical Examiner must comment on positive history (pg. 2), abnormal physical findings (pg. 3), and provide follow-up recommendations (pg. 4).
• Medical Examiner must sign on page 4.
EMPLOYEE SPONSOR / PARENT
• All fields on page 1 and 2 must be filled out. Examinee or parent/employee sponsor must sign on page 2.
• Submit copies of all laboratory tests and additional medical reports with DS-1622.
• All Lab tests and medical reports must be in English, and identified with full name and date of birth of examinee.
• Keep originals as a permanent record. Do NOT submit by U.S. Mail or by courier service (e.g. FedEx or DHL).
Submit the DS-1622 and other documentation via email in PDF format to MEDMR@state.gov (preferred), or by fax to the Medical Records Department
at 202-647-0292. If you wish to confirm that your exam forms were received, email MEDMR@state.gov.
VII. Medical Examiner comments on significant patient medical history and items checked "yes" on page 2 / section II. Use additional pages
if needed.
VIII. CLINICAL EVALUATION: Newborn exam cannot be accepted if completed before four (4) weeks of age
1. Height/Length
2. Weight
3.Pulse or HR (REQUIRED FOR ALL AGES
4. Blood Pressure (age 3 and Over)
and NEWBORNS) RECORD
in. or
lb. or
cm.
kg.
percentile
percentile
5. Head Circumference
6. Development Appropriate for Age
Yes
No
(18 months and under)
If NO, attach Development Screen and explain below with detail in assessment / plan
in. or
7. Gestational age at birth
cm.
8. Immunizations Reviewed
percentile
Yes
No
Immunizations current?
Yes
No
IX. PHYSICAL EXAM
Notes
Check each item as indicated.
Normal Abnormal
NE
(Describe each abnormality in detail. Include pertinent
Check "NE" if not evaluated.
item number before each comment)
1. General/Constitution
2. Development
3. Skin
4. Eyes
5. Ears/Nose/Throat
6. Neck/Thyroid
7. Lungs/Thorax
8. Cardivascular
(Record murmurs/abnormalities)
9. Abdomen
10. Genitalia
11. Anus/Rectum
12. Musculoskeletal/Spine/
Extremities (Note limitations)
13. Lymph nodes
14. Neurologic
DS-1622
Page 3 of 4
Name of Examinee
DOB
X. LABORATORY ANALYSIS
NO LABORATORY TESTS REQUIRED FOR INFANTS
For ages 1 year and above, all tests are required unless otherwise specified. Results from previous 12 months are acceptable.
COPIES OF LABORATORY REPORTS MUST BE SUBMITTED FOR REVIEW AND MUST BE IN ENGLISH
1. Hematology (age 1 and over)
%
OR
gms%
Hematocrit
Hemoglobin
3. Chest X Ray (PA and lateral) - Required only if TST >
2. Tuberculin Skin Test : REQUIRED
for ages 1 and over (unless previously positive)
For baseline status in a child who will live overseas in a likely endemic TB area.
10mm, positive IGRA or clinically indicated.
TST Results:
mm of induration
Date:
Results:
IGRA Results:
Date:
Interferon Gamma Release Array: (may substitute for TST if > 5 y/o or
In those with previous BCG)
Date:
Yes
No
Date:
Previous active tuberculosis
Yes
No
Date:
Previous positive TST or IGRA
Yes
No
Date:
Previous LTBI treatment
Hx of BcG vaccine
Yes
No
Date:
OPTIONAL TESTS: The following test are not required for a medical clearance determination. The expense of performing these exams is not routinely
authorized. The tests may be performed at the clinical discretion of the examiner with patient consent. If performed or previous results are available,
the results may be used by the Department of State in a medical clearance determination and future clinical care of individuals covered under the
Department's Medical Program.
4. Blood Type ( if not previously documented)
Type: ABO
(Rh) Dµ:
(weak D):
5. G6PD (If not previously documented) for malarial prophylaxis
Results:
Date:
6. Blood lead level (recommended screening ages 12 months to 5 years)
Results:
Date:
XI. Assessment or Problem List
XII. Recommendation for Treatment / Further Study / Consultation or
Follow - Up
NOTICE: This form is not complete until all laboratory tests and results from section X are attached and included with this DS-1622 form.
Signature of Examiner
Typed Name of Examiner
Date (mm-dd-yyyy)
Address
Telephone Number
Page 4 of 4
DS-1622
Page of 4